After a pandemic that induced radical changes to our healthcare outlook and the positioning of general practice, we get a budget that almost ignores healthcare?
One of the weirdest budget speech moments was when Treasurer Josh Frydenberg proudly announced the PBS listing of a fantastically expensive (and not so effective) drug by telling the story of a mum who, while dying of cancer, wrote a letter to her daughter to open when she was 12.
Both the mum and her now 12-year-old daughter were present at the budget speech, Josh said, because of the miracle drug, which the federal government had so boldly decided to list as a part of this budget.
Which raised immediately this question: if we are listing the drug only now, how did that help save this women and allow her to live to her daughter’s 12th birthday?
It was pretty awkward, when you think about what the government was attempting to spin: that they had somehow saved this women’s life and allowed her to live to see her child turn 12 by boldly listing this drug. And yet, this was probably the high point of the federal government’s thought process on selling healthcare to the people, and presumably the medical community, on Tuesday night.
In other words, no thought at all. And most of us are hopefully dumb enough to fall for a pretty cynical three-card PBS listing trick (no disrespect at all meant to all those sufferers who will surely benefit, going forward, from this listing).
Ten-year plan, or is it going to be 20 now, or, never?
Meanwhile, back at base, just as Josh was getting near the end of his speech, the Department of Health quietly published the long-awaited Primary Health Care 10 Year Plan on its website.
I guess certain people may have thought that somehow the smoke of the budget, and the upcoming election, would have caused this event to go unnoticed.
But it was noticed, by both medical colleges, the AMA, and both major medical media groups – Australian Doctor and The Medical Republic.
It made for a pretty sad statement on what the federal government must really be thinking about general practice (or not thinking about it).
Rather than taking all the feedback they got on the draft paper and moulding it into something akin to what Health Minister Greg Hunt had promised for the sector, what there was in the draft had been mauled, redacted (metaphorically), disarmed (of funding) and rendered into a plan of puffery, and more questions were now being asked than answered.
One key reversal is that the funding for GPs to register patients under the MyGP scheme, possibly the key piece of policy underpinning the plan, went AWOL.
Another is that the plan to tie MBS telehealth rebates to enrolment has been scrapped.
There is a start date on the plan, but without funding, and worse, with red lights flashing all over the place on the technology needed to be place to be able to do it, with the current Minister Hunt (who was better than most) resigning at this election, and the possibility of a change of government, we think all GPs can safely assume the posting of this plan in its current debilitated form means that all bets are off for now.
The process will probably need to be restarted and it’s not going to be an easy process with the core of the plan – enrolment of patients to their own practices for certain downstream benefits – now in clear disarray.
The publishing of a plan that isn’t a plan marks some eight years of failure by this government to promise and then fail to do something substantive in terms of setting up the primary care sector to properly address chronic care and its future. Remember Health Care Homes? That came in 2016 and went by 2019. This scheme started as an over-70s enrolment program that was meant to be funded and started by July 2020.
Both the RACGP and the AMA were understandably unimpressed, but given the history, they probably shouldn’t have been surprised.
RACGP president Dr Karen Price said: “Tonight’s budget simply did not live up to expectations on the 10-year plan.
“The federal government has failed to provide much-needed funding to support vulnerable patient groups, including those with chronic and complex disease, and deliver on what is needed to ensure a strong future for primary healthcare in Australia.”
AMA president Dr Omar Khorshid said: “… we can see no plan for how its implementation [the 10 Year Plan] will be funded.”
(Well no, because there wasn’t any funding for it.)
“This budget was the last chance for the government to show it is serious about primary care reform by delivering the extra funding needed to improve patient access to high-quality general practice.”
You sort of feel that both colleges and the AMA should be doing a bit of inward examination on what happened and ask themselves how they keep failing to connect to either the powers-that-be in the Department of Health, or, possibly much more importantly, the general public.
The general public has no idea that the federal government has just passed up on locking in a more secure future for general practice, and is happy to keep stalling, and all that this might mean for them on the patient side in the next 20 years.
So why would the federal government give a toss?
The colleges and the AMA are politically pretty ineffective.
The colleges have some excuse.
They were never meant to be, and probably should stop trying to be, lobby groups. They are there for education, training and governance, first and foremost. And as their funding relies on the imprimatur of the DoH in the end, they are in conflict always when they lobby too hard.
The AMA?
It continues to suffer possibly from its split-personality job of representing the interests of GPs and of specialists. GPs aren’t really onside.
Our digital health system is a bigger problem for GPs (but they don’t recognise it, so far)
There’s a bit of an irony in that much of what might really create a better future for general practice, and from this, the whole healthcare system, is not the 10 Year Plan (for now we can forget it anyway thanks to this budget so maybe we can think on this point), but getting our collective act together on digital health technology in Australia.
If you flip through the budget looking for items of digital health progress – as with primary care, there isn’t much to speak of – you can quickly piece together a much greater tragedy for general practice and our healthcare system overall than a disarmed 10 Year Plan.
If you pull at one or two loose budget threads, you can actually unravel what is a giant train wreck for us all.
In the budget fine print, $3 million was set aside to somehow connect the My Health Record system to MyGP, the system by which GPs would be able enrol, register and monitor their patients to their practices, moving forward.
MyGP, which had $50 million devoted to it last year to build, had nothing devoted to it this year, which is strange, because it isn’t working yet, and without it, the whole Primary Health Care 10 Year Plan can’t actually start (which is lucky because the plan isn’t funded anyway).
But to pull at this thread, why, after the fact, do we need to think about linking the MyHealthRecord to MyGP?
Surely, after spending almost $2 billion on the MyHealthRecord, about $350 million a year on the Australian Digital Health Agency (ADHA) and at least $50 million on MyGP more recently, someone would have already thought of that?
Or, better, the systems would have always been designed with some capability of talking to one another?
Seems like a small point to be making?
In the words of one well-recognised industry analyst, the ADHA (which built the MyHealthRecord and maintains it, and oversees the MyGP project) is a “mess of very old technology s*** that is all over the place and political whimsy”.
Or, put more eloquently, the ADHA has failed entirely to oversee our digital health ecosystem evolution in a manner that has properly chaperoned it into a modern digital health communication platform, as has occurred in many other countries, even the US, which as everyone knows has a disastrously complex and unfair healthcare system.
What we see in digital health funding from our government is patch-up, cover-up, buyer’s regret and indecision everywhere.
Often the patch-up jobs are related to the government still trying to force healthcare providers to spend valuable time loading data into awkward formats and sending it centrally to the MyHealthRecord, so the government can maintain we have some sort of platform for data sharing.
Such time wasting doesn’t happen in modern digital healthcare systems. The systems are able to talk to one another and get information from one part to the other, when it is needed.
That we have to allocate additional millions here and there to try to get things to talk to the MyHealthRecord is proof positive that we are a long way behind a modern digital health ecosystem.
Our digital health ecosystem, other perhaps than electronic script writing (which in fairness was started, but not delivered by, the ADHA) is in the technology dark ages.
The most fundamental issue we have is that all of primary care is technologically isolated from the tertiary care system (which, being based on big global platforms, does have data-sharing capability). If primary care is isolated, so too is allied and specialist care. And if they are isolated, you have virtually no hope of managing chronic care as it becomes more loaded over time, and, as importantly, aged care, where currently there are virtually no digital systems at all to even connect to.
The government’s answer to data sharing and interoperability so far has been the MyHealthRecord.
We build a central honey pot, and everyone has to send their data to that honey pot, at great time and expense, and the honey pot will send it back, if you can indeed reach it or talk to it with your old system.
That’s why we have GPs idiotically having to do banal and meaningless patient summaries, which although they are automating the process (and in doing so often making most of the data useless). All this takes time and focus away from patients and real healthcare.
In the US today, more than 95% of healthcare software platform vendors are architectured for the cloud, and include the ability to talk seamlessly over the web to every other vendor, via smart open web sharing technology that includes but is not limited to the Australian Developed resource Fast Healthcare Interoperability Resources (FHIR).
How ironic. The underlying technology enabling the US system to move forward in leaps and bounds while ours stagnates was developed mainly by Australians. But apparently, we don’t have much use for it.
That every digital health product in US is standardised to talk to one another on modern cloud sharing technologies means that, technically, every provider can talk to each other securely, and every patient can get their data from anywhere.
If you compare where the US is to where Australia is, we are like the Bronze Age, to the US’s industrial revolution.
It’s that bad.
It’s why Australian GP patient-management systems, once advanced and innovative in global terms, are now trapping general practice and its valuable patient data in the old MBS payment paradigm.
And in doing so, they are trapping GPs in a bubble where it’s very difficult to make money outside of the MBS.
If GP systems were interoperable, as the government knows they must be, then GPs would be released to work with local aged care groups (once they get systems that people are madly now trying for), with private healthcare groups, with local public hospitals to manage hospital in the home, and create true continuity of care, and of course, to work properly with key allied health care providers, particularly mental health providers.
Regardless of funding reform, GPs would be able to expand their income through channels like private health insurance and working for state funded hospitals.
The federal government has backed itself into a $2.5 billion corner with the MyHealthRecord project, so it’s not unexpected that it resists the temptation to do what the best of the rest of the world has done, and force all our software platform vendors, and through them, every provider, to standardise on this modern data-sharing technology.
But the jig is up a little now. And we know they have been thinking hard about how to do it, without ruffling too many feathers. Some people in the DoH see it and want to do it.
Ironically, one group resisting such a move is the Medical Software Industry Association of Australia (MSIA). The MSIA position is that if the government mandates that everyone should just get their act together and put our healthcare system into the modern era of cloud and seamless secure data sharing, as they have in the US, and by various methods in some smaller European countries, our “innovative and highly valuable medical software sector” would collapse under the weight of capital requirement to recast their products for a proper interoperable healthcare set-up.
And if that happens, the whole healthcare system will be endangered.
It’s a scare tactic (or they actually believe it themselves) from a pretty effective lobby group and they can do it, because there is some truth in what they are saying.
Some local vendors, some of them long term and committed, will struggle and even collapse if they have to modernise like this.
But what the MSIA isn’t telling the government, or thinking through, is that venture capital and even private equity (which traditionally does not put up money for early innovation) is falling all over itself in the US, Israel and parts of Europe to fund this transformation in healthcare.
The US is transforming at speed now as a result of this money, but mainly as a result of the government putting its best foot forward five years ago and demanding that the software vendors, and through them providers, all get their act together and update their technology for the greater good of the system.
If the Department of Health mandated interoperability in the system via some sort of regulatory deadline for everyone equalising on this smart new technology within, say, five years, as they did in the US five years ago now, then there would be a stampede of investment in the sector and you wouldn’t know yourself for the innovation that the sector would start throwing off.
So whether knowingly protecting its old legacy businesses, or naively believing its own rhetoric, the MSIA is doing everything it can to stall innovation in healthcare in Australia, and stall the introduction of technology that we already know from the US is revolutionising healthcare delivery in many ways.
Quick stat for everyone:
Ninety-five per cent of medical software platform vendors in the US, Israel and certain advanced European countries are cloud based, FHIR (a modern web data sharing standard for health) or equivalent and open API (smart outward-facing programs that allow other web apps to easily talk to your app) web enabled to share data seamlessly between products.
Guess how many of those types of businesses we have in Australia.
Less than 12%. Yes, 88% of our software system vendors here, and more than 95% in primary care, are 1980s-style technology: local server-bound software products.
Who can look at this statistic and think Australia’s healthcare system is on the right track?
Who can explain to anyone that this stat is OK?
Technology is the deal breaker that a lot of people aren’t seeing at the moment.
Some key CTOs, particularly some state-government-based ones and some key policy makers in the DoH, do see it.
But as this budget has shown, politics tends to trump common sense, especially when there is an election in the wings.
If and when we do manage to equalise our technology on modern web data-sharing technologies, we will open our healthcare system to a whole gamut of new possibilities for efficiency, funding and better patient management.
For one thing, you can’t manage what you can’t measure, and without interoperability in the system, a GP can’t measure outcomes because a GP has no data to share to do it. If a GP can’t measure outcomes, the government can’t pay based on outcomes.
With seamless data sharing, you can accurately measure outcomes, and start paying properly and effectively for outcomes.
Data sharing is also the secret to better healthcare AI outcomes, something that so far has been mostly hot air, but which has enormous potential (we have a good story out of the Mayo Clinic on this in coming weeks).
Finally, better data sharing means patients truly can have access to meaningful data when and where they want it.
Data is useful only in context. Point of care is context and this new technology makes data available to patients at most of their key points of care. This is as opposed to the My Health Record mindlessly gathering everything it can from the system in one giant messy and mostly unstructured record, which is difficult to get to, and much harder to decipher.
With interoperability via modern data web-sharing technologies, healthcare equity can be addressed.
This is one giant thing going on now in the US where healthcare equity is the mother of all their healthcare problems.
If you’re a GP, and you don’t think much about your tech and what it means to the future of general practice, then definitely ask your college rep why your technology is nothing like your banking app, when with a few swift regulatory changes, it could easily be in a few years’ time.
The bogeyman payroll tax and other horror practice survival stories show
Finally, if you didn’t tune in to David Dahm’s webinar on Payroll tax, PRODA and other emerging government compliance issues for practices on Wednesday night this week (perhaps you were watching the Shane Warne memorial?), then it really is worth a look.
Honestly, maybe even make yourself a box of lightly buttered popcorn to sit back and watch – it’s that sort of show.
But censor’s warning: it’s mostly a horror show.
I’d give it an X rating for one particular slide, after which I literally had some poor practice manager punching in not a question but expressions of despair, as she was ticking off everything for her practice set-up (of more than 20 doctors) that was wrong.
“What am I supposed to do?”
[A sidenote: Lucasz, our resident lawyer panellist was on the chatline helping this manager as best he could.]
At that post, as moderator, I messaged Dahm to say, “slow down, you’re scaring some people”, but David is not a sugar coater. He didn’t slow down much.
Dahm had a very experienced lawyer, Lucasz, as his sidekick on the show as a sort of reference point for those that might have been aghast at some of the examples.
The effect of a good lawyer on a panel can be clarity. At one point, Dahm paused to throw to said lawyer for a clarification: “Lukasz, can you define what this constitutes a little more simply for our audience?”
To which Lukasz replied deftly: “That would be fraud, David.”
Ouch.
For what should be a very boring topic, tax mostly, I was on the edge of my seat for most of the session. And I’m in media, not medical practice administration or ownership.
Personally I’m an ostrich when I can be on this sort of stuff, figuring that either things won’t be as bad as people say, or, I’ll get a slap on the wrist at most for not paying attention by some understanding soul in authority.
But when you see one Western Sydney practice slapped with nearly $1 million in back payroll tax on a tribunal judgment, and then the mess than such cases can create over many years, you probably don’t want to be an ostrich in this game.
I had one medical finance software vendor saying offline that Dahm was just trying to scare up business.
He wasn’t.
Dahm is perhaps an overly straight and enthusiastic shooter.
But he meticulously researches and references his work.
He did the webinar for free and he has provided all and sundry with a lot of detailed material in his webinar to consider all the implications of a few very real and converging factors around compliance for medical practices in the near future:
- All offices of state revenue, bar perhaps WA, are circling recent payroll tax case rulings with a view to clawing back payroll tax from medical practices that are not organised the right way, particularly in money flows and “tenant doctor” contract alignment
- A recent AMA webinar on the subject had an AMA rep on the webinar admitting in front of the NSW state tax commissioner he thought that at least 40% of practices aren’t compliant, sort of setting off a lot of worry among practice owners (I guess more so because he made in this admission in front of a tax commissioner)
- At the same time, the ATO is closing in on a few other aspects of a doctor’s financial structures, including family trusts, but also on the basics of tax, which will be made a lot more obvious to them soon as they roll out e-invoicing, which they are. It’s not such practice structures and accounts that are in tax office cross-hairs. Doctors who contract have been getting things wrong as well, which was OK once but now that the ATO is loving the idea of entirely digital audit trails, and mechanisms such as e-invoicing, which gives them granular data to run algorithms on, things are changing.
- Services Australia is changing a lot too, to be fair, mostly in a good way to service doctors better digitally, but they haven’t given a tonne of thought unfortunately to how their new processes relate to tax compliance. Sometimes process and compliance are clashing, and guess what, the ATO doesn’t care if Services Australia led you astray.
As I say, I’m not one to watch horror or to face the music if I can help it.
But I do recommend you steel yourself, download the deck, and even the comments stream, and watch the show. I’m thinking you will least then be forewarned in some way.
I’m not going to ruin an ending, but it’s actually not a tragedy.
The good guys (GPs) make it through (those that open their eyes and react).
You can view the webinar here and view or download the deck below. You can also read David, Lukasz and Jeremy’s responses to the questions asked during the webinar here.
If you have any questions you want answered from watching it, please email talia@medicalrepublic.com.au and we will get them answered for you.
